Air transportation safety recommendation A95-17

Reassessment of response to Aviation Safety Recommendation A95-17

Night training

Background

On 03 December 1993, a Britten-Norman Islander BN2A-20 aircraft, operated by Arctic Wings and Rotors, was involved in a fatal accident at Tuktoyaktuk, Northwest Territories. The Board determined that a magneto impulse coupling, worn beyond the prescribed limits, resulted in the failure of the right engine. Following the engine failure, the pilot mistrimmed the rudder and was unable to maintain control of the aircraft.

The Board made 6 Aviation Safety Recommendations as a result of the accident. Transport Canada's (TC) response to these recommendations has now been received; the extent to which the safety deficiencies are being resolved is assessed below.

The Board concluded its investigation and released Aviation Investigation Report A93W0204 on 18 October 1995.

TSB Recommendation A95-17 (October 1995)

In January 1993, following the investigation of a twin-engine turbo-prop aircraft accident at Moosonee (TSB report A90H0002) in which neither of the pilots involved had received the required night training and the regional Transport Canada inspectors had not observed that the training had not been conducted, the Board recommended that

TC responded in August 1993 that the Manual of Regulatory Audits (MRA) (published since occurrence A90H0002) directed the audit staff to check the companies' flight training programmes. In addition, TC notified the regional Air Carrier staff of this matter and instructed its Quality Assurance Review team to ensure that the verification of night training did occur.

This occurrence is another example of a night accident in which the pilot had not received the required night training. Notwithstanding Transport Canada's continuing efforts to strengthen its processes for regulatory audit and surveillance, some commercial pilots are still not receiving the required night training. Since the skills required for safe night operations require reinforcement through periodic night training, the Board recommends that

Transport Canada's response to Recommendation A95-17 (September 1996)

Transport Canada, in reviewing this accident report along with other recent fatal accidents in air taxi operations, has set up a task force to review the safety of air taxi operations, including night VFR. The Safety of Air Taxi Operations Task Force (SATOPS) will commence early in 1996 and will examine all aspects of this aviation environment, including the effectiveness of surveillance and inspection by Transport Canada, the regulatory setting, pilot licensing, training and checking requirements, and human factors such as company management attitudes toward safety. An Air Carrier Advisory Circular will be released to advise industry about SATOPS.

TSB assessment of Transport Canada's response to Recommendation A95-17 (November 1996)

In its reply, TC indicated that it has set up a Safety of Air Taxi Operations Task Force (SATOPS) to review air taxi operations in Canada. TSB staff recently confirmed that the Task Force is presently defining its terms of reference and that by the fall of 1996, the industry will be invited to provide input to the Task Force.

The consultative process of the task force has the potential, in the long term, to identify many more issues affecting air taxi operations than those addressed by the Board recommendations. However, the reply from TC does not indicate any interim action to correct the deficiencies already identified by the Board. Of particular concern are those safety deficiencies that prompted Recommendations A95-17 and A95-18. These recommendations were a follow-up to previous recommendations on night flying requirements and the effectiveness of regulatory follow-up to audits. Occurrence investigations continue to uncover shortcomings in TC's overview of the smaller air carriers, such as the ineffective verification of mandatory pilot training; yet, TC has indicated no plans to address this in the short term.

Given that the SATOPS Task Force could deal with the issue of safety in commercial night VFR operations, the reply to Recommendation A95-16 is assessed as having Satisfactory Intent. However, because there is no indication by TC to take interim action to address the perennial issues of lack of pilot night training and non-compliance by operators, the replies to Recommendations A95-17 and A95-18 are assessed as being Unsatisfactory.

TSB reassessment of Recommendation A95-17 (November 1997)

No indication by Transport Canada to take interim action to address the issue of lack of pilot night training. The SATOPS final report, after validation by Industry, Transport Canada and NAV CANADA is to be released in early 1998.

Therefore the assessment remains as Unsatisfactory.

TSB reassessment of Recommendation A95-17 (January 1998)

No change since the last reassessment. The SATOPS final report is to be released in early 1998.

Therefore the assessment remains as Unsatisfactory.

TSB reassessment of Recommendation A95-17 (April 1999)

No change since the last reassessment. A SATOPS Implementation Plan is being developed which may address the safety deficiency but no change yet.

Therefore the assessment remains as Unsatisfactory.

Transport Canada's response to Recommendation A95-17 (September 1999)

This issue was not addressed by SATOPS. Conducting a one time special audit of all commercial air operators to confirm that pilots have received night take-off and landing training is not considered a practical response to this recommendation. TC will propose an amendment to the Manual of Regulatory Audit checklists OP7 & OP8 that will make specific reference to the requirement for night take-off and landings. In the interim, regions will be advised by memo for Dir CBA that this requirement should be added to all planned audits.

TSB reassessment of Recommendation A95-17 (February 2004)

The recommendation is not addressed under SATOPS as originally indicated. Transport Canada apparently addressed concern by advising the regions that requirement to confirm night training be added to all planned audits (supposedly post 1999). Transport Canada's analysis of the ongoing regional audit results should address the safety deficiency.

Therefore, the response to Recommendation A95-17 is assessed as Satisfactory in Part.

As such, Further Action is Unwarranted with respect to A95-17 and the status is set to Inactive.

TSB review of Recommendation A95-17 deficiency file status (April 2014)

The Board requested that A95-17 be reviewed to determine if the deficiency file status was appropriate. After an initial evaluation, it was determined that the safety deficiency addressed by Recommendation A95-17 is also addressed by the previous Recommendation A93-05 and by Recommendation A95-18.

It is therefore appropriate to follow the progress on night training safety issues through Recommendations A93-05 and A95-18.

Therefore, the assessment remains as Satisfactory in Part.

Consequently, the status of Recommendation A95-17 is changed to Active.

Transport Canada's response to Recommendation A95-17 (August 2017)

TC agrees in principle with the recommendation.

TC did not conduct the one time audit recommended by the TSB in 1995. However, in 1996, TCCA established a new regulatory regime, replacing Air Navigation Orders with the CARs. 

The CARs require commercial operators to follow more stringent training and checking requirements which address the concern. CARs 703.98 is the training regulation and CARs 723.98 is the training standard.

All training programs must be submitted to and approved by TC, and validated during PVIs.

This recommendation is to confirm that night and Instrument Flight Rules (IFR) training is conducted properly. CARs 703.98 and CARs 723.98 addresses all aspects of the risks associated with this recommendation.

TC believes that this more comprehensive and ongoing regulation and surveillance process exceed the benefits to be gained by a one-time audit.

TSB assessment of Transport Canada's response to Recommendation A95-17 (February 2018)

TC has taken a number of actions to address the safety deficiency identified in Recommendation A95-17, regarding the conduct of a special one-time audit to confirm that commercial pilots involved in night multi-engine operations are receiving the required night training. These include the following:

• The Canadian Aviation Regulations (CARs) have replaced the Air Navigation Orderswith more rigorous flight crew training requirements;
• Under CARs Part VII, commercial air operators engaged in multi-engine night operations must establish and maintain an initial and recurrent ground and flight training program to validate the multi-engine night proficiency of their pilots; and
• Through its surveillance program, TC audits flight crew training records by utilizing system and process level surveillance procedures, which verify and validate operator compliance with multi-engine night training requirements under CARs Part VII.

Although TC did not perform a special one-time audit, the Board believes that the actions taken by TC have substantially reduced the risks associated with the safety deficiency identified in Recommendation A95-17.

Therefore, the Board considers the response to Recommendation A95-17 to be Fully Satisfactory.

Next TSB action

This deficiency file Closed.